Failure to Maintain Safe Condition of Essential Equipment
Penalty
Summary
The facility failed to maintain essential electrical and patient care equipment in safe operating condition for five residents. Observations and interviews revealed that one resident's fall mat had peeling covers, compromising its integrity and the homelike environment. The fall mat was intended as an intervention for a resident with severe cognitive impairment, high fall risk, and a history of falls, as documented in the care plan and medical records. Both the LVN and DON confirmed that the mat's condition was unacceptable and did not meet facility standards for safety or environment. Additionally, four residents were found to have bed remote controls with frayed or exposed wires. These residents had varying degrees of cognitive impairment and physical dependency, with some at high risk for falls. Staff, including CNAs and the DON, acknowledged during interviews that exposed or frayed wires on bed controls posed a risk of electrocution and should have been reported immediately to the maintenance department for replacement. Observations confirmed the presence of these hazards in resident rooms, and staff admitted to not noticing or reporting the issues in a timely manner. Review of facility policies and procedures indicated that maintenance services are responsible for ensuring all equipment is safe and operable, and that staff are expected to identify and report hazards. The policies also emphasized the importance of providing a safe, clean, and homelike environment, and specifically addressed the need for electrical safety and the prevention of accident hazards. Despite these policies, the facility did not ensure that equipment such as fall mats and bed controls were maintained in safe condition, resulting in the identified deficiencies.